What does a patient’s excessive concern about their health indicate to the therapist?
Is it the first manifestation of hypochondria, or rather a process of somatization?
How can these two diagnoses be differentiated? To answer these questions, let us consider current perspectives on hypochondria.

Hypochondria is a complex diagnosis that often evokes mixed reactions in therapists due to the particularities of its clinical picture and the diagnostic criteria (ICD and DSM).

According to ICD-10, the essential feature is a persistent preoccupation with the possibility of having one or more serious and progressive physical disorders. Patients manifest persistent somatic complaints or a persistent preoccupation with their physical appearance. Normal or commonplace sensations and appearances are often interpreted by patients as abnormal and distressing, and attention is usually focused upon only one or two organs or systems of the body. Marked depression and anxiety are often present, and may justify additional diagnoses. 

However, the ICD-10 classifies hypochondriacal disorder under the category of somatoform disorders (F45), without defining it as a personality disorder.

At the same time, hypochondria is not included in the official DSM-V classification as a personality disorder. 

Diagnostic criteria for hypochondria previously existed in DSM-III and DSM-IV. In DSM-V, it was removed and incorporated into the broader category of somatic symptom disorders, which is a rather non-specific diagnosis that distances the essence of this condition from clinical reality.

Regression Markers in Hypochondria:

Some hypochondriacal people, those who drive physicians to distraction with a litany of vague and changing complaints that never respond to treatment, use regression to the sick role as a primary means of coping with upsetting aspects of their lives. By the time they are persuaded to consult a therapist, they have usually built up an additional and virtually impenetrable wall of defensiveness deriving from having repeatedly been treated like a spoiled child or willful attention seeker. They expect clinicians to try to expose them as malingerers. Consequently, the therapist whose client uses regression to the sick role as a favored defense must have almost superhuman reserves of tact and patience—all the more so if the patient’s pattern of taking to the sickbed has been reinforced by other rewards of that position (“secondary gain”).

Hypochondria and other kinds of regression into relatively helpless and childlike modes of dealing with life can be a kind of cornerstone of a person’s character. Where regression, with or without hypochondria, constitutes someone’s core strategy for dealing with the challenges of living, he or she may be characterized as having an infantile personality. This category did not survive after the second edition of the DSM, but some analysts have lamented its disappearance.

Hypochondria and Somatization: 

Although one sometimes sees a client with both, hypochondriasis should not be confused with somatization. 

In the former, there is no disease process, despite the patient’s worry or even conviction of illness.

In the latter, there are diagnosable ailments related to stresses that the person somehow cannot process emotionally. Sometimes, of course, doctors are sure they are dealing with a hypochodriacal patient and eventually learn that the person has been suffering from an obscure, undiagnosed illness. Therapists have to take care to leave open a mental space for the possibility that a difficult client who seems clearly either hypochondriacal or somatizing may be ill with a

systemic problem that has not been identified.

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy

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